Cultural humility beats competence in psychotherapeutic settings

The emphasis on cultural context of diagnosis and treatment of psychiatric disorders was expanded in the DSM-5, but the commonly used term for this orientation, “cultural competence,” is potentially misleading, according to a panel of experienced clinicians participating in a workshop at the annual meeting of the American Psychiatric Association.

“I am not even sure how competent I am in my own culture,” said Richa Bhatia, MD, medical director of the Child and Adolescent OCD Institute at McLean Hospital, Belmont, Mass.. The remark was representative; like other panelists in a workshop developed by the Association of Women Psychiatrists, she de-emphasized the importance of becoming fluent in the specifics of a culture relative to simply being sensitive to variations in cultural landmarks and milestones.

Ted Bosworth/MDedge News

Dr. Lourdes M. Dominguez (left) and Dr. Sherry P. Katz-Bearnot

“The good news is that we have come a long way in regard to recognizing the importance of cultural sensitivity,” added Sylvia L. Wybert Olarte, MD, a psychiatrist in private practice in New York and chair of the APA workshop. “We need all psychiatrists to be culturally competent. This is not just for a few specialists.”

However, she, like others, expressed concern about the label “competence.” “Cultural humility is really a much better term,” Dr. Olarte said. The reason is that the term “humility” captures the qualities of openness and acceptance, not just an understanding, of the values of others. Furthermore, it encourages clinicians to consider and manage their own prejudices, values, and biases in order to allow them to be effective in the therapeutic interaction.

In the DSM-5, a systematic outline is provided for eliciting culturally relevant information from the diagnostic interview and incorporating it into a therapeutic plan. Cultural competence is important for communication and for building patient trust, but the panelists uniformly agreed that it is not necessary to be fluent in the culture of the patient to be an effective clinician.

“Cultural identification is fluid, and patients have multiple identities,” said Lourdes M. Dominguez, MD, associate professor of psychiatry at Columbia University, New York. Recounting her work with first responders to the Sept. 11, 2001, World Trade Center attack, Dr. Dominguez offered care to police officers associated with a variety of cultures. In addition to different ethnicities and sexual orientations, this included the culture of law enforcement itself. The key for all patients was an ability to convey the message that the patient was being heard.

“The us-versus-them mentality in law enforcement limits the options when fellow officers are not providing the support they need,” Dr. Dominguez explained. “First, you need to win their trust.”